(The highlight colours used in this column link to the colours in the case notes at left).
STAGE 1. Analysing the task to be clear that you are providing the appropriate information
This is a referral letter to endocrinologist (Dr Tristan). The fact that this letter is to an endocrinologist provides extra information that this case focuses on diabetes.
STAGE 2. Reading the case notes to identify:
a) the main purpose of the referral - what do you want the reader to check or know?
Notes on last consultation, (and the reference back to the symptoms in the previous one) suggest suspected diabetes mellitus.
b) information which could be relevant to the reader when making their decision
You need to provide information directly relevant to the development of the condition. This could include:
- family and social history
- previous medical history and treatment
- immediate medical history leading to the referral
STAGE 3. Organising the information into a cohesive (unified and interconnected) whole
There are common ways of organising information in formal referral letters, but the structure can vary according to the main focus of the letter. A common structure for such letters that could be used here is:
a) The first paragraph usually includes the immediate reason for referring i.e. usually the problem presented at the most recent appointment (that the doctor is uncertain about, or has no specialisation in, or needs support with)
b) This is often followed by a summary of the medical/treatment history that is relevant to the reason for the referral. In this case:
- family and social history
- previous, relevant medical history
- details of examination and treatment immediately leading to referral
c) Finally there is generally a paragraph (or part of a paragraph) formally requesting further treatment (if relevant, and referring to any useful reports or test results that are included). |
